Archives for March 2015

90% of people say that talking with their loved ones about end -of -life care is important, but… only 27% have actually done so.

As medicine has advanced and life expectancy has increased, our society has come to see the subjects of dying and death as taboo. The topics are often avoided out of fear and discomfort. However, there are some things medicine simply cannot stop. Dying and death are inevitable but, how your end-of-life care is managed is in your hands.

In general terms, Advance Directives are documents that speak for you when you are unable to do so. These documents are created, by you, to specifically outline your wishes, beliefs and values regarding your health care. The specifics of: long term health care, mental health care, breathing machines, tube feedings and other medical procedures can be addressed per YOUR wishes. Here we’ll briefly address two of the most commonly seen Advance Directive documents (electronic links provided below).

Living Will:

A Living Will document details your wishes for only the time period when you are close to death or in a vegetative state. It does NOT allow for another person to make health care decisions for you.

Durable Power of Attorney for Health Care (DPOA-HC)

A DPOA-HC allows you to appoint a “health care agent” who will be able to make health care decisions for you, ONLY in the event that you are unable to do so. This document does not go into effect until two physicians “activate” it by documenting that you lack the capacity to make these decisions yourself. It is vitally important that you chose a person who knows, understands and will follow your wishes.

In the state of Wisconsin, there are several document options; each considered to be a DPOA-HC. The most commonly seen are: The State of Wisconsin Durable Power of Attorney for Health Care, Respecting Choices and Five Wishes. While the details of the document vary, the goal is the same.

Just as important as completing an Advance Directive is making sure it gets to where it needs to be. Providing your healthcare team and your loved ones with the document(s) allows for more open, honest communication focused on your wishes, hopes and dreams.

Advance Directives allow you the opportunity to discuss and document what is important to you so your end-of-life experiences can be just as meaningful as the way you’ve lived your life. While Advance Directives cannot encompass every possible medical scenario, they can provide the basis for thoughtful, YOU-based end-of-life care.

Cancers and blood disorders are being diagnosed at earlier stages and earlier ages. This is positive as treating earlier stage cancers allows for better treatment outcomes than treating the later stage cancers generally does. However, the treatments we often prescribe – surgery, radiation, chemotherapy, additional medications – can affect a patient’s fertility.

Fertility is defined as the ability to produce young. Fertility effects from treatment can be permanent or temporary. To protect this ability, it is important to address fertility concerns early in the cancer diagnosis so proper planning can be done.

Common diagnoses whose treatments affect fertility include:

Breast Cancer

Lymphoma

Prostate Cancer

Testicular Cancer

Leukemia

The key to successful protection is communication with your healthcare provider. Each patient situation is evaluated and can often be treated with options such as freezing eggs or sperm. It takes time to arrange and complete these procedures. You and your provider team can discuss any delays in treatment and balance this with the quality of life that can be provided by future children.

It began simply enough. An inquisitive colleague asked me if we have more breast cancer in our area than elsewhere. I had been asked this before, and I still did not know. But I should know.

The “Big Three” cancers in the US are prostate, lung, and colorectal for males and breast, lung and colorectal for females. Together these problems encompass half of our cancer problems. Over 31,000 Wisconsin residents were diagnosed with cancer in 2013 and 30% of the females with cancer had breast cancer. (A little less than 1% of all breast cancers are in men.) We expect 4300 new Wisconsin women to be diagnosed with this in 2014. Breast cancer incidence started rising in 1981, reached a plateau from 1986-2000, then slowly fell. Breast cancer deaths fell slowly after 1991. Was this due to mammography, which took hold in 1980-1990? Largely so.

Breast cancer incidence declined in our state by 8% between 1995 and 2010. Wisconsin’s breast cancer mortality also declined 27.9% over that time frame. The efforts of many different groups are reflected in this improvement. There are the obvious factors of mammography, improved surgical and radiation techniques, advances in oncology drugs, and genetic testing. In addition, there is breast cancer awareness, self-examination, improved socioeconomic status, attention to obesity, and caution regarding menopausal hormone therapy.

Are all women at risk? Certain risk factors cannot be modified: age, heredity, ethnicity or race. Obviously female gender is the most notorious. Factors that are avoidable or can be manipulated include weight reduction, excess alcohol consumption, and exposure to hormones.

When analyzing a population’s incidence of cancer, it is important to also be aware of the age group involved. Aging is a distinct risk factor for cancer. If a woman is currently 20, her risk of developing breast cancer in the next ten years is less than 1 in 1700. But if she is 60, the risk is 1 in 29. Certain features modify a population’s risk: poverty, irregularities of reporting, and race. Additional factors exist too. It goes beyond “air and water quality.”

So, do we have more breast cancer here? Wisconsin’s incidence of breast cancer for 2006-2010 was 122.5 per 100 000 females. This contrasts with 128 for Brown County, 143 for Door, 100.7 for Kewaunee, and 123.7 for Outagamie. The statisticians interpret these numbers in light of a concept termed confidence intervals. That is the statistical way of asking if these numbers are different. When one applies confidence intervals, we discover these numbers are not different. The ranges overlap meaning the incidence of breast cancer in Brown, Door and Outagamie County is essentially equal to that of Kewaunee County or to Wisconsin overall. Although it shocks our awareness, it should not provoke the Door County residents to migrate 9 miles south to Kewaunee.

Why have people asked these questions about incidence? Are we more aware of friends’ health in our electronic age? Are we and our friends getting older, falling into the ever-higher risk groups? Is the rate truly rising and no one realizes it? We need to focus on the things we can control. Strides have been made in the past 20 years.

Earlier this month the New York Times ran an article titled “Cancer’s Random Assault.” It described the results of a study published in Science Magazine that proposes the majority of cancer can be chalked up to random bad luck.

The authors of the study; Dr. Christian Tomasetti, a mathematician, and Dr. Bert Vogelstein of John Hopkins School of Medicine; reported that approximately ⅔ of the cancers they studied were due to random genetic mutations and only about ⅓ were due to hereditary or environmental causes. In other words, ⅔ of the cancers studied were due to bad luck and the rest was due to things we can control or prevent.

My initial reaction was a defensive one. Surely these scientists were not proposing that cancer was due to having been dealt a poor hand at life’s game of cards. However, upon reading the article I understood the quest they had proposed. They were merely asking the question, “How much is due to chance? Is it just some bad statistical lottery?” The results were provocative and surprising.

Many people want to know what they can do to prevent cancer. Many who have cancer are filled with the guilt that they have possibly contributed to their disease. The more we know and understand the forces and circumstances to cancer development the better position we are in to prevent or cure the disease.

We have known for some time now that cancer is driven by cell mutations. Basically, when healthy cells divide, errors occur. Sometimes errors can lead to uncontrolled cell growth and ultimately cancer. Statistically speaking, the more cells that divide and copy, the more likely a cell will make an error that leads to cancer. For example, people who are repeatedly exposed to cigarette smoke have increased lung cell injury. This leads to increased cell division to repair the damage. Over time, the increased cell division increases the likelihood a mutation will occur that may lead to a lung cancer.

But not all tissues are as cancer prone as others. The large intestine is more prone than the small intestine. The lungs and skin are more prone to cancer than say, the spleen. Why is that? Why do some people get cancer and others do not?

Their research more clearly defines just how much cancer development is due to environmental and hereditary factors. The rest is due to presumably random complex genetic functions. This highlights the need for more research in areas such as genetic profiles and stem cell growth, repair and patterns. It is this direction that holds the future of cancer cure and prevention.

It important not to take away the message that “Gee, getting cancer is just bad luck!” We have the ability to improve our chances; our luck if you will. Between ⅓ to ½ of all cancers can be prevented by lifestyle modification. That’s a lot!

If I can improve my odds of not getting cancer as much as 30 to 50% by behaviors I choose; maintaining a healthy diet and weight, not smoking, and wearing sunscreen; and the actions I take; regularly undergoing cancer screening for breast, colon and skin cancer; I will take those odds.